Homeless Hotline Shelter Screening and Diversion Form

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Homeless Hotline Shelter Screening and Diversion Form Purpose: To provide people who are literally homeless a path into shelter (Front Door, Overnight, Tier 2; CHOICES, Engagement Center, Huck House); to refer to facilities that are a more appropriate option than shelter (crisis stabilization); to make appropriate referrals to support services; to divert if possible. Triage Performed By: ________________________________ Date/Time: _____________________________ Type of Triage: ____Telephone All information on this call is confidential; it will only be shared with partnership agencies providing services to you. Is this okay with you? Yes No

Begin Intake: Thank you for calling HandsOn Central Ohio, Homeless Hotline. My name is (STATE YOUR NAME).

Collect the following information: Need to ask for HUD First Name _______________________________

Last Name______________________________________

Alias_____________________________________

Social Security Number____________________________

Primary Race______________________________

Secondary Race__________________________________

Ethnicity__________________________________

Date of Birth_____________________________________

Telephone Number_________________________

Military Veteran? _________________________________

Family Intake Only: Household Composition: HoH (Adult#1)________________________________________________________________ (Adult#2Name/DOB)_____________________________(Adult#3Name/DOB))___________________________________ Minor Child Age & Gender: ______________ ________________ ______________ ________________

________________ ________________

______________ ______________

_______________ _______________

1. Before we start, are you currently under the age of 18? Yes No a. If yes, I can provide you with the number to Huckleberry House, a Teen Crisis Center (614-294-5553). 2. Household composition: Single Adult Family with minor child Unaccompanied minor a. Single adult, skip to question #6 b. Family w/minor child, continue to question #3 c. Unaccompanied minor *STOP* Please refer to Huckleberry House @ 614-294-5553 Page 1 of 11 2/5/16

Homeless Hotline Shelter Screening and Diversion Form

3. Do you have legal custody of the minor children? Yes No a. If yes, move to next question. b. If no,*STOP*. Intake must be completed with the family’s Head of Household (HoH). Only people with legal custody of the minor child can be considered HoH. 4. Are you currently connected with Franklin County Children Services (FCCS)? Yes No a. If yes, is your case worker aware of your current situation? Yes No b. If yes, refer client back to FCCS case worker to see if they have available resources. If FCCS cannot help, we can proceed with intake for shelter. c. If no, move to the next question. 5. Have you ever been assisted by Stable Families before? Yes No a. If yes, move to next question b. If no, the client may qualify for a Stable Family referral if they have a minor in the household, an income and have not been in emergency shelter within the last 6 months 6. Do you currently have a lease in your name? Yes No If yes: a. Are you being evicted? Yes No b. Have you been to court? Yes No c. Do you have a set out date? Yes No Set out date __________________________  If client has not permanently exited the household, they are not considered HUD homeless and not eligible for shelter. Please refer client to 2-1-1 for community resources. Domestic Violence/Human Trafficking Are you experiencing any violence against you physically or sexually (by an intimate partner) where you live or are staying right now that is making that place unsafe for you to remain? 7. Are you currently in a domestic violence situation with an intimate partner? Yes No a. If No, Skip to question #11 b. If Yes: I can provide you with the number to CHOICES (614-224-4663). HOMELESS HOTLINE can also offer to connect if warm transfer is possible. 8. Are you in a safe place now to talk to me about this?

Yes

No

9. When was the last incident of abuse? (must be within 30 days to qualify for DV shelter)_________________________  If abuse was within 30 days, Refer to CHOICES Domestic Violence Shelter where they may have additional resources to help with housing crisis and address additional concerns a. If within 30 days, REFER TO CHOICES b. If not, continue with intake process

10. Is there other safe housing where you can stay when you leave? Yes No a. How many nights can you stay there? (If fewer than 10 days, REFER TO CHOICES) _____________ 11. Are you presently feeling pressured/threatened to do things (such as sex or labor) you didn’t want to do? Yes No Page 2 of 11 2/5/16

Homeless Hotline Shelter Screening and Diversion Form 12. Are you presently exchanging sex or labor for something of value? (such as: food, shelter, drugs, clothing, money) Yes No a. If yes to #4 or #5: May I provide you with the number for the local hotline that can help you? HOMELESS HOTLINE can also offer to connect if warm transfer is possible. Central Ohio Rescue and Restore Coalition (614-285-4357) If you are seeking shelter, I need to get some basic information from you. 13. Are you presently on the streets or in a camp or without a safe place to stay tonight? 14. Are you connected with Maryhaven Outreach?

Yes

Yes

No

No

15. What is the zip code of your last permanent address? __________________________________________________ 16. From the following choices, which best describes the location of your most recent housing? Columbus Out of State: ___________________ Franklin County Don’t Know Ohio but Outside of Franklin County Refused 17.

Where did you stay last night? Need to ask for HUD 1 2 3 4 5 6 7 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 8 9

Emergency shelter, including hotel or motel paid for with emergency shelter voucher Transitional housing for homeless persons (including homeless youth) Permanent housing for formerly homeless persons (such as SHP, S + C or SRO Mod Rehab) Psychiatric hospital or other psychiatric facility Substance abuse treatment facility or detox center Hospital (non-psychiatric) Jail, prison, or juvenile detention facility Staying or living in a family member’s room, apartment, or house Staying or living in a friend’s room, apartment, or house Hotel or motel paid for without emergency shelter voucher Foster care home or foster care group home Place not meant for habitation (e.g. a vehicle, an abandoned building, bus/train/subway station/airport or anywhere outside); inclusive of “non-housing service site (outreach programs only)” Other Safe Haven Rental by client with VASH housing subsidy Rental by client with other ongoing housing subsidy Owned by client, with ongoing housing subsidy Rental by client, no ongoing housing subsidy Owned by client, no ongoing housing subsidy Long-term care facility or nursing home Residential project of halfway house with no homeless criteria Rental by client with grant per diem transition in place subsidy Don’t Know Unknown

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Homeless Hotline Shelter Screening and Diversion Form 18. How long have you been staying there? (Need to ask for HUD) One day or less Two days to one week More than one week, but less than one month One to three months

More than three months, but less than one year One year or longer Don’t Know Refused

19. General location where you stayed last night_______________________________________________________ 20. How much longer are you able to stay at this location? _______________________________________________ 21. Why did you have to leave this place? ____________________________________________________________ 22. Where else might you be able to stay? _____________________________________________________________ 23. What is the primary reason that you are homeless? ___________________________________________________ 24. What is the secondary reason that you are homeless? _________________________________________________ 25. Are you entering from the street or emergency shelter?

Yes

No

If yes, approx. date started __________

26. In the last three years, how many times have you been homeless? _______________________________________ 27. In the last three years, how many months have you spent either on the street or in a shelter? __________________ 28. Have you ever spent any time in shelter?

Yes

No

a. b. c. d.

If yes, Enter Date_______________________ Exit Date______________________________________ Which shelter? _______________________________________________________________________ Why did you exit shelter?_______________________________________________________________ Did you receive any financial assistance? Yes No i. If yes, what was the month and year?_____________________________________________ e. Why do you need to return to shelter? ____________________________________________________

*************************Thank you for providing that basic information*********************** One of my primary roles is to help callers find a place other than shelter to stay. This could be with a family member or a friend or by helping connect people with other resources that I know are available. Please tell me a little more about your current situation? (Listen for what their needs are).

Page 4 of 11 Release Date: April 1, 2015

Homeless Hotline Shelter Screening and Diversion Form I now have some addition questions to help me better identify resources that might be helpful.

Try to Divert, (please use the following questions): 29. Do you have any income? Yes No a. If yes, do you receive income from any of the following sources? Yes/No

Source of Income Earned Income (Currently Working) Unemployment Insurance Supplemental Security Income (SSI) Social Security Disability Income (SSDI) Veteran’s Service Connected Disability Compensation Veteran’s Non-Service Connected Disability Compensation Private disability Insurance Worker’s Compensation Temporary Assistance for Needy Families (TANF) General Assistance Retirement Income from Social Security Veteran’s pension Pension from a former job Child Support Alimony or other spousal Support Other Source

Amount of Monthly Income

30. Do you receive any following non-cash assistance? (Not calculated in monthly income) Yes/No

Source of Non-Cash Assistance

Supplemental Nutrition Assistance Program (SNAP) Special Supplemental Nutrition Program for Women, Infants and Children (WIC) TANF Child Care services TANF transportation services Other TANF-funded services Section 8, public housing or other ongoing rental assistance Other Temporary Financial Assistance 31. How much money do you have access to right now (to determine if a motel or rent is possible)? ________________ 32. What is your housing status in this moment? Homeless: Staying on the street Imminently losing housing within the next 14 days

Page 5 of 11 Release Date: April 1, 2015

Homeless Hotline Shelter Screening and Diversion Form  If you are not yet homeless, I would like to provide you with the number to our information and referral line, where specialists may be able to help you with community resources. The number is 614-221-2255. Fleeing a Domestic Violence Situation (This question was already covered this in question #3. The question does not need to be asked again. Simply check the box if applicable.) Homeless Only Under another Federal Statue (not eligible for shelter in Franklin County, unless literally homeless.) At risk of losing housing  If you are not yet homeless, I would like to provide you with the number to our 2-1-1 line, where specialists may be able to help you with community resources. The number is 614-221-2255. Stably Housed (Staying in rental, with friends/family, etc.) 33. If you are staying with friends/family, can you stay there again tonight? Yes No a. If no, How long have you been staying there and why do have to leave now?

34. If we are unable to provide you shelter for the night where will you stay? _________________________________ 35. Who do you usually call when you need help? _______________________________________________________ a. Can you contact him or her? Yes No 36. Do you belong to a church, another faith-based organization, AA or another recovery community? Yes a. If yes, is there a member willing to help you? Yes No b. If yes, have you made contact to see if they have any resources available to help their members? Yes No

No

37. Would there be anyone else you could possibly stay with for at least the next three (3) to seven (7) days if I was able to assist you in connecting with case management services/transportation assistance/limited financial support? (If yes, give 2-1-1 number.) Yes No 38. Would any of the following resources help you stay remain in your current housing? (If yes, give 2-1-1 number) Utility assistance to prevent disconnection Help resolving issues with your landlord (Community Mediation Services and Columbus Urban League) Help resolving your current eviction notice (Community Mediation Services and Columbus Urban League) Mortgage assistance to prevent foreclosure First month’s rent to establish housing Security deposit to establish housing Rental assistance to prevent eviction Help applying for SSI or other non-cash benefits Employment Mediation (family, roommate, landlord) Case Management Page 6 of 11 Release Date: April 1, 2015

Homeless Hotline Shelter Screening and Diversion Form Transportation Other: _______________________________ 39. Do you have all of your personal belongings with you? Yes No a. If no, where are they being stored?____________________________________________________________ 40. Are you presently under the influence of alcohol or drugs? Yes: I can provide you with the number to Netcare (614-276-2273). If the caller appears to be using alcohol or other substances, HOMELESS HOTLINE staff should continue by asking the caller if s/he is willing to go to detox. (If yes refer to Maryhaven Engagement Center via ROW Van or CPD, as clients cannot self-refer.)

No: “Okay. Well I need to let you know that if anyone shows up to a shelter or returns to a shelter after using alcohol or other drugs, the individual shelter will make a determination about whether or not the individual is able to safely stay there for the night.” Now I have some questions I need to ask about your ability to remain safe while in shelter tonight. 41. Are there any medical conditions that you know you have such as diabetes, seizures, high blood pressure, or a heartrelated condition for which you are not receiving treatment or have run out of medication? Yes No If yes, please share these conditions as soon as you arrive at the shelter today/tonight. 42. Are you presently thinking about hurting yourself or someone else? Yes No If yes: While Netcare does not provide shelter, it does help link people with mental health services. It also provides mental health (crisis) services. Prior to assigning you to a shelter I need for you to be seen at Netcare. Netcare’s Number is 614-276-2273 you may call or present there yourself. They have 2 locations 199 S. Central Ave and 741 E. Broad Street. While HOMELESS HOTLINE is unable to provide transportation, if you are unable to get there on your own I can call CPD to have you transported for your own safety. Do you need for me to call CPD for your safety? Yes No

I have a few questions I need to ask about other community services you might receive.

43. Have you ever been referred to a community mental health provider or are you receiving services from a community mental health provider now? Yes No a. If yes, which one? _______________________________________________________________________ b. If yes, do you have a case manager presently? (Is s/he aware of your situation?) c. If no, ask if they are interested in Mental Health Services? Yes No a. If yes then say “Netcare’s Number is 614-276-2273. Netcare does not provide shelter, but it can link you with mental health services”. 44. Are you currently linked with VA Services? Yes: Enrolled Now No

Don’t Know Refused to Answer Page 7 of 11

Release Date: April 1, 2015

Homeless Hotline Shelter Screening and Diversion Form

45. Have you ever served in the US Military? (Question is collecting HUD “Veteran Status” required data element: HOMELESS HOTLINE Worker to enter in CSP data field.) Yes Don’t Know No Skip to question #47 Refused to Answer 46. What was your discharge status for the military? I have some specific categories I will read to you, please select the one that is most accurate. (HOMELESS HOTLINE Worker to enter in CSP data field.) General under honorable conditions Under other than honorable conditions (OTH) Bad Conduct Uncharacterized Dishonorable Don’t Know Refused If the caller answers questions 19 - 21, record information in CSP and attempt to divert with SSVF Resources in real time. Also please make sure a veteran bed is not available if client is eligible. If they can go to veteran resources please facilitate this process.

We also have to do a registered sex offender check 47. Are you now, or have you ever been, a registered or convicted sex offender? Yes Don’t Know No Refused to Answer 48. Are you now, or have you ever been, subject to community notification? Yes Don’t Know No Refused to Answer 48 a. If yes to question 47 or 48, did the sexual offense involve a minor?

Yes

No

48 b. If yes to question 45 or 46, what is your current classification? (If the person is unsure read the options below.): Tier I Pre AWA Habitual Sex Offender w/ notification Tier II Pre AWA Sexual Predator Tier III Pre AWA Aggravated Sexually Oriented Offense Pre AWA Sexually Oriented Offender Pre AWA Child Victim Offender Pre AWA Habitual Sex Offender w/o notification Pre AWA Child Victim Predator 49. Background check completed? (Check one below) Not a question but a process – it is completed while the person is on the phone. Local (Free) National (Paid) Both (Local & National) NA (Client Diverted or not Homeless, call interrupted, etc.)

Family Intake Only: If this is not a family intake, skip to question #51 50. Do you or any adult in your household have any active warrants? a. Adult #1 background check completed Yes No b. Adult #2 background check completed Yes No c. Adult #3 background check completed Yes No

Yes

No

Page 8 of 11 Release Date: April 1, 2015

Homeless Hotline Shelter Screening and Diversion Form 51. Contact Resolution: (check one) Client Advised to Call Back Once Discharged from Current Shelter Client called from Shelter - Advised to Remain There Client Ineligible Waitlisted Diverted Admitted/Scheduled for Intake Refused Services Call Interrupted or Incomplete Scheduled for Appeal No Show; Other Family Stand By List Scheduled for In-Person interview

52. CSP: Type of Shelter Reservation: Check one Front Door Reservation: First Time Homeless Front Door Reservation: Returning Participant reassigned to Front Door Shelter Tier 2 Shelter Reservation: Returning participant with prior Navigator Services Tier 2 Shelter Reservation: Returning participant with prior VA Case Manager Tier 2 Shelter Reservation and Navigator Reservation: Returning participant without prior Navigator or VA Services and referral for Navigator Program made by HOMELESS HOTLINE

If Diverted (Don’t need shelter tonight) Complete this section and STOP Client Diverted to: Select Here

# 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Disposition Reason Referred to Alcohol/Drug Treatment Facilities Diverted to Friends or Family Referred to Choices Referred to CIS Stable Families Program Referred to City/County Assistance Referred to HOCO 211 Diverted to current household location Referred to Landlord Mediation and Resolution (Legal Aid, Columbus Urban League or Community Mediation Services) Referred to Mental Health Services Referred to ODJFS Diverted to Rental Assistance Referred to Utility Assistance Referred to Veteran Affairs Referred to SSVF Program Other:

If NOT Diverted (Need shelter tonight) Resume Intake Here Page 9 of 11 Release Date: April 1, 2015

Homeless Hotline Shelter Screening and Diversion Form

53. Based on completion of the form, individual may be eligible for shelter? When Assigning a Shelter Bed:

Yes

No

Based on our conversation and bed availability, it looks like there is a bed available at _____________________ shelter.

Would you like me to go ahead and make a reservation for that bed for you?

Your reservation has been entered.

You need to report to ______________________ shelter within the next 4 hours. Please be aware, if you do not report to the shelter within 4 hours, you may lose your bed. (The shelter’s number is XXXXXX-XXXX. It is your responsibility for you to contact them within the next 4 hours if you are unable to make it there.)

You are responsible for getting to the shelter.

Please provide any additional notes regarding this triage or any unusual incidents that occurred while completing this triage.

If placed on the Waitlist (needs shelter tonight but there are beds available) I see that you are eligible for shelter however currently we do not have any beds available. What I am going to do is place you on a waitlist. Now that you are on the waitlist, it is your responsibility to check in with us each and every single day to see if a bed has become available. We do a bed count each morning at 8:00 am and then again at 9:00 pm. Although you are only required to check in once each day, we recommend that you call in at each bed count. This only increases your chances for a bed. We cannot hold them. Each morning at 7 am, we do a system update. Anyone who did not make their required phone call the day before will be removed from the waitlist. If you are removed and you call back in for shelter, you will need to complete another intake and get added back to the bottom of the waitlist. Page 10 of 11 Release Date: April 1, 2015

Homeless Hotline Shelter Screening and Diversion Form

Due to high demand for shelter, we are not able to guarantee requests for specific shelters. If you are offered a bed, you have the option to accept or decline what was offered. If you decline a bed, you will be removed from the waitlist and will need to call again and complete another intake in order to be considered for shelter.

If placed on a Family Stand By list (If call is Monday – Friday 8 am – 7:30 pm) In order to be considered for family shelter, you will need to meet with one of our Family Resource Specialists in the Family Resource Center. I can transfer you to them now so you can set up an appointment to come in. If they are unable to answer the phone, please leave a voicemail and a Resource Specialist will return your call as soon as possible. (If call is anytime that FRC is unavailable) In order to be considered for family shelter, you will need to meet with one of our Family Resource Specialists in the Family Resource Center. Currently the FRC is closed. Please continue to stay where you are and contact us on the next business day. (If caller states that they have NOWHERE to stay until next business day) Since you do not have a place to stay tonight and the FRC is closed, we can offer an Emergency Overnight Stay at our Van Buren Family Shelter. Please understand that this is a one night stay only. You can enter shelter in between the hours of 8 pm and 11 pm. You will need to exit the following morning so do not bring anything more than an overnight bag. You will need to call Homeless Hotline the following day. If FRC is open, you will schedule an appointment to be seen.

Page 11 of 11 Release Date: April 1, 2015